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Air Embolism Linked To Central Line Death

Bob Aller   December 29, 2019

Key Facts

  • In Florida, a Palms West Hospital ICU nurse removed a central line while the patient was sitting up
  • Within minutes, the patient suffered severe chest pains, couldn’t breathe, lost consciousness, placed on life support, without regaining consciousness died several days later… chart notes indicated possible air embolism
  • Palms West Hospital decided not to make the required report to state health authorities, initiating a cover-up
  • Patient’s family claimed Palms West doctors told them their son died from Broken Heart Syndrome
  • Death Certificate falsely indicated death from acute drug intoxication
  • Medical Examiner reviewed medical records and recalled the patient’s body prior to cremation
  • An autopsy determined the probable cause of death was air embolism
  • Palms West Hospital, (an HCA hospital), claimed that removing a central line while the patient is sitting up meets the medical standard of care

Introduction:

Each year approximately 5 million acutely ill patients in the U.S. receive a central venous line catheter (central line).  Central lines are used to infuse medicines, blood products, fluids, and nutrients into a large vein when a small vein would be inadequate. About 8% of hospitalized patients receive a central line. However, the improper withdrawal of a central line can cause a fatality from an air embolism. “It occurs as a result of a pressure gradient that allows air to enter the bloodstream, which can subsequently occlude blood flow.” It is reported that an air embolism can form in 1-2 seconds and block the flow of blood (and oxygen).

Air embolisms occur all too often. In one report from the Pennsylvania Patient Safety Authority, there were 74 air embolism incidents between 2004 to 2011.

Air embolism

CMS established the rule (joined by insurance companies) that if a central line is improperly withdrawn causing a fatality from an air embolism, it is a Never Event that is not reimbursable. The National Quality Forum asserts that Never Events are preventable errors that point to a serious healthcare facility deficiency.

Nevertheless,  on August 18, 2016, an RN withdrew a central line improperly at Palms West Hospital in Loxahatchee, Florida. Instead of adhering to the hospital policy of positioning the patient lying down flat in the “Trendelenburg” position, with feet above the head, an RN withdrew the central line when the patient was sitting up. This Never Event raises a significant question: Did Palms West provide adequate training for ICU nurses on central line removal?

After an autopsy, the Palm Beach County Medical Examiner determined an air embolism was the probable cause of the death of patient Joshua Dzeidzic. 

According to a lawsuit filed by the family of Mr. Dzeidzic the hospital administration covered-up the death by failing to report the incident to authorities and failing to comply with the required corrective steps. As part of the cover-up, a hospitalist even issued a misleading death certificate that stated the death was “natural.” Claims made in the lawsuit were confirmed in a state investigation for the Centers for Medicare & Medicaid Services (CMS). The Director of Patient Safety of Palms West frankly admitted the hospital staff made the decision to withhold reporting the incident. However, no reason for the cover-up was provided.

The lawsuit asserts that rather than admit to medical errors, hospital doctors shifted blame to the patient’s mother. The patient, Joshua Dziedzic, had been recovering from a drug overdose. According to the lawsuit, a doctor told Josh’s mother that Josh felt so guilty about letting her down by having an overdose on drugs that he suffered a fatal heart attack.

Palms West Hospital is owned by Hospital Corporation of America (HCA). As a “for-profit” corporation, HCA owns 185 hospitals. Revenue for 2018 was $46.48 billion. Due to HCA’s degree of profitability, HCA is considered a “darling” of Wall Street. In this case, according to the lawsuit, Palms West improperly billed Blue Cross Blue Shield for Joshua Dziedzic’s care following the air embolism, violating an insurance company rule that prohibits such billing.

In addition, according to a source knowledgeable about HCA employment practices, this Never Event, if acknowledged, could have had a potentially adverse impact on bonus payments to Palms West management.

In this report, the patient’s family describes what they saw and experienced.

Sources: Documents reviewed for this report include the Centers for Medicare and Medicaid Services (CMS) Statement of Deficiencies, the Palms West Hospital Plan of Correction, and an Autopsy Report and Medical Examiner’s Investigation Report. In addition, court documents from the lawsuit brought by the family of Joshua Dziedzic and responses to the lawsuit from Palms West Hospital were reviewed. Statements obtained from Dziedzic family members were edited minimally for clarity and brevity.

(Links to PDF supporting documents are provided at the end of this report.)

Joshua Dziedzic Prescribed Opioids In High School                       

Joshua Dziedzic was a 17-year-old student at Ida Baker High School in Cape Coral Florida when he was in an auto accident.  Both of Josh’s feet were crushed. After multiple surgeries replacing the bones in his arches with donors’ bones, his feet were reconstructed. Following these surgeries, Josh suffered from continuing pain. He was sent to a pain clinic where opioids were prescribed.  For Josh, like so many others, opioids led to substance abuse.

However, eight years later, at age 25, Josh had turned things around.

Josh’s sister, Stacey

Josh’s Sister, Stacey: “Josh was doing really well. He had been clean for about 15 months. His goal was to become a physical therapist. He was working at a gym as a personal trainer, which he loved. He was passionate about fitness. He loved helping people. He had completed a semester at Palm Beach State College, doing well. He was in a good place.”  

A Relapse

Nevertheless, on the morning of August 8, 2016, Josh was found unresponsive by his roommate. After a 911 call, Josh was taken to Palms West Hospital in Loxahatchee, Florida. He was suffering an acute drug intoxication from opioids. His roommate also called Josh’s parents, who lived two and a half hours away in Ft. Myers. They promptly drove the 125 miles, across southern Florida, to be with Josh at the hospital.

Hospital Treatment

Upon admittance to the Palms West Emergency Room, Josh was put on a ventilator.  He was then admitted to the ICU. A central venous line catheter (central line) was placed in Josh’s left internal jugular vein.

Josh was unconscious during the first few days of hospitalization. The doctors didn’t know if he would survive. Josh’s family booked a hotel room they used for showering and naps. They stayed with Josh during the days and nights. At least one family member slept next to him on a recliner each night. Most often, it was his mom. Gradually, Josh got better.

Recovering From The Drug Overdose

Joshua Dziedzic, 2015

Seven days after admittance Josh was taken off the ventilator. Soon, he was alert, talking, and eating. He participated in physical and occupational therapy sessions.  The clinical notes of August 18th indicate Josh was able to walk in his room and exercise at the edge of his bed.

As a well-conditioned personal trainer, Josh’s fitness likely played a positive role in his recovery. Josh and his family were told he was about to be discharged from the ICU.  In addition to his parents’ presence, Josh’s sister, Stacey, and his brother, Paul Jr., came to see and encourage him towards full recovery. Though the central line remained in Josh’s neck, it was time for the central line to be removed.

Central Line Removal Policy

Trendelenburg position to prevent air embolism

The Palms West written policy for removing a central line required that a patient lies flat on their back facing up with the patient’s feet 15 to 30 degrees above the head in the Trendelenburg position. Patients are instructed to face away from the side of the central line. The patient is instructed to slowly take a deep breath, and then slowly breathe out, while the nurse steadily removes the catheter. The policy requires that gauze is placed on the insertion and held for 3-5 minutes. Then, the patient is moved to a sitting up position and gauze is again placed on the insertion site. The Palms West central line removal policy requires that the gauze over the exit site is then covered with a semipermeable dressing.

Josh Visiting With His Mother

Joshua’s mother, Barbara

Three days after he was taken off the ventilator, Josh was sitting up in a chair next to his mother, Barbara. They were watching the film Willy Wonka and the Chocolate Factory, one of Josh’s favorites. His mother recalled that they were in good spirits. After all, he had survived a near-death ordeal. Josh was able to share his feelings.

Josh’s Mother, Barbara: He told me he was really, really sorry. He didn’t want it to happen again. I assured him, it’s okay. We all make mistakes. We’re going to get up and we’re going forward. That’s what matters. He told me he was hungry. That told me he was getting better. I had snacks ready. We ate together.

Nurse Removes Josh’s Central Line

As Josh and his mother were visiting, a new nurse came into the room. RN Linda Truempy said she had come to remove the central line.

Josh’s Mother, Barbara:  As Josh was sitting next to me, Nurse Truempy took out the stitches, holding the central line in place and then pulled the central line tubing out of his neck. I glanced over and I saw this big hole in his neck and I said, “Wow, that’s really big.” And she said, “Yeah, I wonder why there’s no blood coming out of that.” I stood up to look more closely at the hole in his neck. Josh grabbed my hand and said, “Mom, I don’t feel good.” And I said, “Why don’t you feel good?” He said, “My chest really hurts.” Josh grabbed his chest. He said, “I can’t breathe.” Nurse Truempy ran out of the room to find help.

COMMENT: An expert in dressing the exit site of central lines emphasized that the hole in Josh’s neck should not have been open and visible, as described by Josh’s mother. The central line site should have been covered with gauze as the line was withdrawn to stop any bleeding and shield against an air embolism. Second, running out of the room was wrong. Josh was abandoned while suffering from acute chest pain. The nurse could have initiated a Code Blue, calling a team to the room. Alternatively, she could have shouted for help. (Nurse Truempy stated she had worked on the Palms West ICU unit for nearly 2 years. In total, she had 30 years of nursing experience.)

Did the Palms West ICU room have faulty communication devices?

Why did Nurse Truempy run out of the room?

Dr. Belayet Hossain Diagnoses Josh Has Anxiety 

According to the lawsuit, Dr. Belayet Hossain, entered the room.

Josh’s Mom, Barbara: Dr. Hossain said he thought Josh was just having anxiety problems. “Let’s give him some medication.” Then he left. The nurse came over and gave Josh the medication ordered by Dr. Hossein. Then she put a band-aid on his neck to cover the hole. 

COMMENT: An expert in the management of central lines stated that if Dr. Hossain had made a differential diagnosis and considered the possibility of an air embolism, there may have been a chance, however remote, to save Josh’s life. The Infusion Nurses Association (INS) highlights the need to “suspect air embolism with the sudden onset of… chest pains” after central line removal. INS lists a series of steps to implement when an air embolism is suspected.

Josh’s Mom, Barbara:  Soon after Dr. Hossain left the room Josh started having convulsions and it was bad. Again, the nurse ran out of the room to get help. I was there by myself with Josh. Then Josh had a bad seizure. I held him up so he wouldn’t fall off the chair. It felt like forever until they came back into the room. It took three staff to put him in his bed. Then the charge nurse came in and told me to leave. I said, “I don’t want to leave.” And she said, “You have to leave.” I finally left.

When Josh’s mother returned to the room, Josh was on a mask providing 100% oxygen (air contains 21% oxygen). He was soon placed on a ventilator. Barbara said she never saw an airtight dressing on the site of the central line, but instead, all she saw was a band-aid over the site. Josh never regained consciousness.

Chart Notes 08/18/16 at 2:20 PM  …The patient was intubated for respiratory failure…suspect air embolism / pulmonary embolism.  The patient was placed on a ventilator.

Josh’s Mother Reports Dr. Hossein Claimed Josh Suffered A Heart Attack Because He Disappointed Her

Joshua’s mother, Barbara

Josh’s Mom, Barbara: Afterward, Dr. Hossein came back and said Josh had a heart attack from broken heart syndrome (Takotsubo cardiomyopathy). Dr. Hossein said Josh knew he had disappointed me so badly that it probably caused his heart attack. I felt terrible. I loved him dearly.

Dr. Damaan Aden (hospitalist) came in another time when my kids Stacey and Paul Jr. were with me. He also said they thought Josh had suffered from broken heart syndrome.

According to Harvard Health, more than 90% of broken heart syndrome cases are in women ages 58 to 75.

In response to the Dziedzic lawsuit, Palms West Hospital denied the lawsuit’s claim that the doctors told the family that Josh died from broken heart syndrome.

Also, Palms West claimed in a legal filing titled a “Plaintiff’s Request for Admissions” that it was not beneath the standard of care to withdraw a central line while a patient is sitting up. However, this Palms West legal claim contradicts the hospital’s own policy for central line removal.

No Staff Would Talk To Barbara

Josh’s Mother, Barbara

Josh’s Mom, Barbara: A neurologist came into Josh’s room in the middle of the night. She looked at Josh and left without saying a word. The next morning there was another new nurse that I’d never had before. Other nurses on the floor wouldn’t talk to me. I tried asking nurses, you know, “Hey, how come you’re not Josh’s nurse today? Oh, we switched.” It seemed odd. No nurse would talk to me.

Chart Notes

08/21/16 at 2:06 PM: … Currently unresponsive, In deep coma from anoxic brain encephalopathy, No corneal reflexes; Highly likely brain death; the family declined any further tests, and requested to proceed with the withdrawal of care in AM. 

Friends & Family Say Goodbye

Josh’s Mom, Barbara: On Sunday the room was filled with Josh’s friends coming and saying their goodbyes. They were friends from the gym where he worked and from college. They came all day… Our family was always a very close family. I was a stay at home mom, my kids and that’s all I knew… taking care of my kids and being with my kids. Josh was a big part of our family. He always did things with his brother, his sister and his father and I. He was a caring person. He was dearly loved by our family.”

Chart Notes

08/22/16: Brief Death Summary Note…patient passed away at 8:50 AM with the family members at the bedside.

Josh’s father, Paul Dziedzic Sr.

Josh’s Father, Paul Sr:

Around 8:30 AM on Monday Josh’s life support was withdrawn. Barb was standing with me. I held his hand. I just looked at the heart monitor and waited for it just to stop. It wasn’t long. 

Misleading Death Certificate

Joshua Dzeidzic’s death certificate was completed by Dr. Damaan Aden, the hospitalist. Though Josh had recovered from his drug overdose when the central line was withdrawn, Dr. Aden certified Josh’s death was caused by acute drug intoxication and was a “natural” death. Under Florida law, however, Josh’s acute drug intoxication was either a suicide or an accident. Dr. Aden’s misleading certification of Josh’s death as “natural” would trigger the unraveling of the hospital’s cover-up.

Funeral Services For Josh 

On August 25th, the Dziedzic’s held funeral services for Josh in their home town of Ft. Myers, 125 miles from the Palms West Hospital. After the funeral, Josh’s body awaited cremation. However, since Josh was scheduled to be cremated, the approval of the Medical Examiner was required under Florida law.

The Medical Examiner’s staff reviewed the misleading death certificate. Since the death was listed as natural, certain medical records were requested in digital format by the Medical Examiner. According to the lawsuit, instead of providing the requested digital records, the hospital sent 1,788 pages of paper records. The stack made the Medical Examiner’s job more time-consuming. After reviewing Josh’s medical records, it was clear an autopsy was required.  The Medical Examiner’s office arranged for Josh’s body to be picked up in Ft. Myers and taken back the 125 miles to Palm Beach County for the autopsy.

The autopsy was performed.

Autopsy Results Released

The autopsy results, issued in November 2016, contradicted the misleading death certificate prepared by Dr. Aden.

Cause of Death: Complications of probable air embolism following removal of central venous catheter due to treatment of opiate overdose. Manner of Death: Accident. 

The Medical Examiner issued a new death certificate, changing the manner of death from “natural” to “accident”.

After Palms West received the Autopsy Report, the hospital did not challenge the Medical Examiner’s Autopsy. Yet, the hospital continued to cover-up the death for another 7 months, until the State conducted an unannounced onsite investigation.

Nurse Truempy Interviewed by Florida Agency For Healthcare Administration

In June 2017, Nurse Truempy was interviewed by an investigator from the Florida Agency for Healthcare Administration, acting on behalf of CMS.  Ms. Truempy admitted removing the line when Josh was sitting up in a chair. She also said she should have removed the line while Josh was lying flat on his back and holding his breath. The CMS report showed that Nurse Truempy’s explanation was not consistent with the hospital’s policy for central line removal. The policy required that the feet are elevated above the head, with the head 15-30 degrees below the feet in the Trendelenburg position, unless contraindicated.

The Director of the ICU was also interviewed. The Director claimed to have told Nurse Truempy that Josh may have suffered an air embolism due to the improper removal of the central line.

The Director of Patient Safety and Risk Management admitted that the hospital administration decided not to report the incident. However, no explanation was provided for the failure to report the incident.

Why Did This “Never Event” Occur?

During the CMS investigation, Nurse Truempy did not provide any “possible” reason for her admitted error. However, when Nurse Truempy received her RN training roughly 30 years before this tragedy, the standard of care for central line withdrawal was much different. The  CMS investigation did not reveal any previous training of ICU nurses in central line management at Palms West.

Just In Time Training?

The Palms West Plan of Correction states that six months after Josh’s death, on February 28, 2017, the hospital completed “Just in time” (JIT) education on central venous catheter removal as per “hospital policy” for 53 of 54 ICU nurses. The concept of just in time training refers to training only when it’s needed, instead of ahead of time. It appears that Palms West decided that “Just in Time” training was needed since a patient died six months earlier. It’s akin to putting up a traffic light after too many fatalities.

Since lives are at stake, the Agency for Healthcare Research and Quality (AHRQ) recommends training ahead of time, (rather than waiting till after a tragic incident occurs). AHRQ recommends that education on central line matters should be provided upon hire, annually, and whenever the protocol is added to job responsibilities.

Michelle Feil, MSN, RN, Senior Patient Safety Analyst Pennsylvania Patient Safety Authority. reports that “CVC insertion and removal should only be performed by health care professionals who have received adequate training and who have been assessed as competent in performing the procedure.”

Did Palms West fail to provide staff training upon hire and annual staff training for central line removal each year before Josh’s death?

Palms West Central Line Policy Fails To Comply With AHRQ National Standards

After the death of Joshua Dziedzic, the hospital failed to conduct a mandatory root cause analysis. When the CMS investigation was conducted in June 2017, the Director of Patient Safety and Risk Management told an investigator that when the autopsy report was received they “knew what the root cause was.” Yet, it appears the Palms West hospital administration likely did not realize that their policy for central line removal did not comply with “occlusive” national standards.

Since 1989, Congress has designated the AHRQ as the agency that promotes national standards for health care. AHRQ literature (AHRQ Quality Indicators Toolkit, see page 9) states that the dressing to be used on the exit site for a central line is, in sum, an “occlusive” dressing. Simply put, the site is blocked off or closed to prevent the creation of an air embolism. In some cases, occlusion is achieved with an ointment that covers the site, along with a wound dressing.

Granted, different hospitals have differing policies. The UC San Diego Health central line removal policy provides considerable detail, consistent with the national standard set by AHRQ.

However, the Palms West policy for central line removal failed to require a “sterile occlusive” dressing in its policy.

Palms West Hospital Denies Air Embolism

In litigation with the Dziedzic family, (Palms West Hospital’s Response To Plaintiff’s Request For Admissions), Palms West denies that a venous air embolism was the proximate cause of Josh’s cardiorespiratory arrest.

However, the hospital failed to indicate any alternative cause of Josh’s death differing from the  Medical Examiner’s determination that an air embolism was the only probable cause of death.

SECTION FROM LEGAL DOCUMENT “PLAINTIFF’S REQUEST FOR ADMISSIONS”

 

Summing Up

Josh’s Mom, Barbara:  When I received Josh’s revised death certificate it said his death was due to an air embolism. It said accidental death. It didn’t say broken heart syndrome. It angers me that they wanted us to believe as parents that we could be the cause of our son’s death.  They knew Josh died from an air embolism.

Josh’s Sister, Stacey:  My mom had told me the neurologist came in the middle of the night and looked at Josh. I called the neurologist.  She said Josh had been brain dead since the incident.  She said there was no point in continuing with treatment.  Even so, Dr. Aden gave us false hope that maybe they could save him.  He knew Josh was brain dead.

 

Joshua’s brother, Paul Jr.

Josh’s Brother, Paul Jr: “When I visited Josh I made sure to tell him that I didn’t care about the relapse.  We were all excited he made it through this experience and that everything was going to be better…  Josh was the kind of person you could always talk to about anything you wanted to talk about, no matter what.  He always cared about what you had to say. He was always willing to be supportive, no matter what he was dealing with.  He was my best friend throughout my entire life.”

Josh’s Mom, Barbara: “I don’t have Josh anymore.  He was my son and he was an important part of our family. There’s a big hole in our family now because he’s not here.  I would have forgiven them if they had been honest!” 

I would have forgiven them if they had been honest!”

 

Hospital Watchdog Team Leader, Suzan Shinazy, contributed significantly to this report. In addition, nurses, physicians, and patient advocates reviewed this case report.

Look for Part II of this report

 

SOURCES:

The Lawsuit Filed By The Dziedzic Family. Read…

Palms West Hospital’s response to the lawsuit. Read…

Palms West Hospital’s Response to Plaintiffs’ Request for Admissions... Read…

CMS Statement of Deficiencies  Read…

Palms West Hospital Plan of Correction Read…

Palms West Policy For Central Line Removal Read

Autopsy Findings & Medical Examiner’s Investigative  Read…

Violations of Palms West Hospital Central Line Withdrawal Policy  Read…

Acts By Palms West That Violated State Law & Hospital Policies  Read…

7 thoughts on “Air Embolism Linked To Central Line Death

  1. Excellent reporting, though heartbreaking on so many levels. Top level, highly paid administrators seem to escape scrutiny in too many cases. Time for changes. Thank you for this reporting, HospitalWatchDog

  2. I have been working in healthcare in some capacity for almost 35 years and while changes and improvements have certainly been made, unfortunately, it often seems to me that the things stay the same or get worse much more often than they change or improve. Sorry, I am not trying to be negative, but that is the reality of 21st century healthcare.

  3. Sorry for the typos. Medical care leaders within hospitals should learn about the concept of normalization of variance and then apply it to the quality assurance process within their hospitals. By not accepting a normalization of variance, the “accident’ described would not have happened. It was not an accident, it was expected, because untrained persons were allowed to remove the central line.

  4. If it was not for Florida’s Wrongful Death Act a.k.a. Florida Free Kill (statute 768.21, subsection 8, which precludes parents of an adult child from filing for wrongful death), Joshua’s parents would have been able to file a wrongful death lawsuit. In addition, a wrongful death case being filed in court would have prevented the insurance fraud and perhaps even brought mandated attention to retraining of the nurse.

    I hear from the families of victims all the time! What this family has been through is awful and yet there are so many more experiencing similar circumstances. There is currently a house bill submitted in Florida to repeal Florida’s Free Kill law. Please learn about it and if you live in Florida or care about someone in Florida, sign our petition that goes to Senate and House members. Info: http://www.FloridaMedicalRights.org and petition: http://www.FloridaFreeKill.org

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